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Unit
Block GO/,
Lot
Date of Mark -out �!
Date of Burial Time
Name of Funeral Home
Authorized by
CITY OF SEBASTIAN 10425
ADMINISTRATIVE SERVICES RECEIPT
Nam CxSlaAlO 1 r1h I ! IcC)(' ❑Cash
Date OKCheck#e�os
❑ Credit
Amount Paid
001001 208001
Sales Tax
001001 220000
Security Deposit
001501 362100
Taxable Rent
001501 362150
Non -Taxable Rent
450010 369900
Airport Badge
001001218010
CobraServe
001501 354100
Code Enforcement Fines
001501 347557
Community Center Revenue
001501341920
Copies
001501 351140
Parking Citation
001501 342100
Police Security Services
001501 329200
Site Plan Review
001501 329300
SubdivisiontPlat Review
001501 329100
Zoning Fees
WIS'N
U - 3 f� t IL ObL U• SDsa-
0 D
C/�b
Total Paid
Intal(
s
Security Dep Held
- Amount $ Check #
White - Dept. of Origin - Yellow - Admin. Svcs. • Pink - Applicant
Funeral Director's Request to City of Sebastian for Burial Opening in Sebastian
Municipal Cemetery
Contact Information:
Kip Kelso, Cemetery Sexton
Sebastian Municipal Cemetery
Phone (772) 589-2545
Fax (772) 228-9927
City Clerk's Office
Cathy Testa
City Hall, 1225 Main Street
Sebastian, FL 32958
Phone (772) 388-8209
ctesta(@cityofsebastian.orq
Funeral Home: _ EAs+v/N,GlS
(Check)
Open Burial Lot Lot_ Block_ Unit
Open Cremains Lot Lot Block_ Unit_
Open Columbarium Niche Nich4'�A Blocke Unit .3
(Circle) N S E W
Burial Date and Service Time: -0MAA2?cy Z ZO/7 2.'00 /O i+J
Deceased Name:
Name and Signature of Lot Owner or Representative:
(Must provide proper documentation of ownership)
Print Name
Signature
Date
I certify that I have determined the ownership of the above described site that all site fees and
administrative fees have been paid and authorized opening of same.
Name and Signature of Licensed f urfey1il Direegtor:
-z> Ls/ uJq//.00A
Print Name
,3 -Ly -/7
Date
I certify that I have checked the owngrship information by viewing the owner's deed and confirming with
Clerk's Office and that all fees have been paid:
Cemetery Sexton Certification:
Cemetery Sexton Date
This form to be provided to Clerk's Office by Sexton for permanent record upon completion.
QTY OF
5EB'"
HOME OF PELICAN ISLAND
Certificate No. 2474
CITY OF SEBASTIAN
Certificate of Interment Rights
IN ACCORDANCE with provisions of the Code of Ordinances of the City of
Sebastian, it is hereby certified that:
Charles & Pearl Koch
855 Floraland Avenue
Sebastian, FL 32958
In and for consideration of the sum of $2,000.00 is entitled to full interment
rights in the Sebastian Municipal Cemetery for the following niche:
Unit 3, Columbarium, Niche 5dsa
of the Sebastian Municipal Cemetery,
as maintained on file in the records of the City Clerk
for use in accordance with the conditions, ordinances, resolutions, rules and
regulations prescribed therefore by the City of Sebastian.
CONVEYED THIS 12th day of August, 2015.
CITY OF SEBASTIAN, FLORIDA ATTEST:
Joseph F. Griffin/
City Manager
Sally A.N�aio, MMC
City Cler
CM of
HOME OF PELICAN ISLAND
City of Sebastian Municipal Cemetery Purchase Receipt
To enable the City of Sebastian to determine the correct rate, and in accordance with cemetery rate
regulations, proof of City residency of purchaser or person for whom lot is intended for interment must
be provided at time of purchase.
ChOcrleS j
�i WHOM
Y55 F lora lanc( five f'L 32g5F
Address
5k9 -73 Lf4
Area Code & Phone Number
Name & Residence Address of Intended Occupant if Other Than Purchaser
Receipt is acknowledged in the sum of:
OFFICE USE ONLY
d " t)ollars ($ ZOOO.o o)
on this I Z �` day of rt 0S f 20 IS for the purchase of the following described
Cemetery Lot(s) and/or Niche(s).
Unit 3 Block W I 'Lot(s)-Niche(s) 5dSQ
for use in accordance with the conditions, ordinances, resolutions, rules and regulations prescribed
therefore by the City of Sebastian.
Additional Fees paid at time of purchase:
Corner Markers (set of 4 - $20) Opening & Closing
Vase and Ring for Niches (cost) �LJ• �5 Interment
Temporary Marker Preparation & Installation
Signature of Purchaser
I:\WW-DATA\Ms-Cemetery\REC EI PT.doc
/W O H
Circle One
Disinterment
TOTAL" $ /2 2.5
�ty of Sebastian
The following documents were provided as Proof of
Residency:
CITY OF SEBASTIAN
FINANCE DEPARTMENT RECEIPT 9923
Koch ❑ Cash
Date 8/12/15 q Check # 53 1
❑ Credit
Amount Paid
001001 208001 Sales Tax
001001 220000 Security Deposit -
001501 362100 Taxable Rent -
001501 362150 Non -Taxable Rent -
450010 369900 Airport Badge
001501 329500 Alarm Permits
001001 216010 CobraServe
001501 354100 Code Enforcement Fines
001501 347557 Community Center Revenue
001501341920 Copies
001501 369900 Miscellaneous Revenue
001501 359000 Other Fines/Forfeitures
001501 351140 Parking Citation
001501 342100 Police Security Services
601010 -148QA U3 COL 5dsa 2000.0
001501 343805 ring & vase 84.2
Total Paid 2084.25
nitials
White - Dept. of Origin • Yellow - Finance • Pink - Applicant
Page 1 of 1
IN MEMORY OF
CHARLES
KOCH
General Information
Full Name
Date of Birth
Date of Death
Charles Koch
Monday, July 26th, 1926
Monday, March 20th, 2017
Service Information
When Saturday, March 25th, 2017,
1:30pm
Location Sebastian VFW Post 10210
Address 815 Louisiana Avenue
Sebastian, FL
32958
Map & Directions
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